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American Journal of  Medical 
Science and Innovation (AJMSI) 

Management of  Procedural Pain in Pediatric Burnt Patients: A Review
Haitham ELsayed Elsadek1*

Volume 3 Issue 1, Year 2024
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v3i1.2567
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: February 26, 2024
Accepted: March 30, 2024
Published: April 04, 2024

Burn injuries are the sixth leading cause of  mortality globally and among the top five causes 
of  injury in pediatrics. Therefore, this study aimed to review the methods and treatments 
for managing procedural pain in pediatric burnt patients, focusing on alleviating burning 
sensations effectively. Data were gathered from various electronic databases spanning 
2015 to 2024 using keywords related to pain management, burn injuries, and intervention 
strategies. Utilizing frameworks like SPIDER, PICO, and ROBIS, 85 articles were selected 
for review, elucidating interventions, pain assessment criteria, and management guidelines. 
The review underscores the progress in effective therapies while aiming to determine the 
prevalence and treatment of  procedural burn pain in pediatrics. Further, it encompasses 
treatment criteria, protocols, pharmacological and non-pharmacological interventions, and 
lifestyle modifications. This indicates that effective treatment options are progressing. This 
review concluded personalized, multimodal pain treatment methods for enhancing the 
health and efficiency of  patients in vulnerable situations.

Keywords
Analgesics, Aromatherapy, 
Anxiety, Burn injury, 
Benzodiazepines, Hypnosis, 
Ketamine, Opioids, Pediatrics, 
Pain Management, Procedural 
pain, Pain perception, Propofol, 
Sedation, Total Body Surface 
Area, Visual Analog Scale

1 Alzahra Hospital Dubai, Sheikh Zayed Rd, Al Barsha & Dubai Health Authority, Headquarters, Sheikh Ahmed Square, Al Jaddaf,
  Dubai,United Arab Emirates
* Corresponding author’s e-mail: dr_hytham3000@yahoo.com

INTRODUCTION
Burn injuries are among the five most common causes 
of  pediatric injuries and the sixth leading cause of  
mortality in the world (Shiferaw et al., 2022a). Almost all 
children with burns endure pain as a result of  a complex 
pathophysiologic process that is usually disregarded, and 
up to 38% of  all pediatric burn patients develop anxiety 
disorders due to pain after hospital admission. All children 
who experience burn injuries experience pain, regardless 
of  the cause, severity, or depth of  the burn (Shiferaw et 
al., 2022a). Further, the injury requires invasive therapies 
such as surgery, recurrent wound care, and wound 
debridement (Preston & Ambardekar, 2020). After these 
surgeries, there may be increased discomfort, leading 
to adverse physiological, psychological, and emotional 
consequences (Shiferaw et al., 2022a). Discomfort and 
distress are significant contributors to the development 
of  acute stress and symptoms of  Post-Traumatic Stress 
Disorder (PTSD) (Unseld et al., 2021). Therefore, it is 
vital to manage pain and anxiety in the treatment of  burn 
pediatric patients. 
Around 19% of  all recorded burn cases in the United 
States involve those under five years old, with a majority 
occurring in their own homes (almost 73%) (Shank et al., 
2019). The majority of  the population is Caucasian (59%), 
20% African American, 14% Hispanic, 2.4% Asian, and 
5% other ethnic groupings. Scalds and contact with hot 
objects are the primary causes of  pediatric injuries, with 
5.4% involving inhalation injuries (Shank et al., 2019). 
There were indications of  potential child abuse in 1861 
cases. Mortality rates range from 0.6% for burns affecting 

less than 10% of  the Body Surface Area (BSA) to over 
84% for burns affecting over 90% of  BSA (Rajarajan, 
2015). Around 200,000 children with burn injuries receive 
treatment in emergency rooms annually, with the majority 
being under six years old (Burgess et al., 2022). 
Furthermore, in the United Arab Emirates, pediatric 
burns account for 64% of  all traumatic injuries in children 
under five years old and have an 8% death rate. Tea and 
hot water are the most common causes of  burns in 
youngsters (Qureshi et al., 2021). However, understanding 
the pathophysiological and pharmacological challenges 
associated with burn trauma is crucial for the successful 
treatment of  pediatric patients with burn injuries (Jeschke 
et al., 2020). Burn injuries are categorized based on the 
burn depth after the initial assessment. Topical treatment 
options include various options, such as debriding 
chemicals and dressings (Qureshi et al., 2021). After the 
wound is healed, the patient is monitored at a clinic under 
the doctor’s supervision, where dressings are regularly 
replaced.. The dressing changes cause significant pain and 
discomfort to the child during wound cleaning, as well as 
anxiety (Qureshi et al., 2021).  
Burn-related tissue damage is considered a severe 
injury and a significant worldwide health crisis (Fagin 
& Palmieri, 2017). Patients with burns suffer from 
psychological and physical consequences as a result of  
their distress, which might result in long-lasting pain. 
Burn pain can be categorized into three types: background 
pain, breakthrough pain, and procedural pain (Fagin & 
Palmieri, 2017). Burns and related procedures can cause 
pain, anxiety, and itch in children, leading to relapse, 



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delayed recovery, and increased healthcare costs (Geagea 
et al., 2022). Inadequate treatment can cause chronic 
sensory alterations and psychosocial sequelae, increasing 
medication needs and negatively impacting children’s 
well-being and quality of  life. Post-burn itch, procedural 
pain, and state anxiety can prevent related consequences 
like post-traumatic stress disorder and their impact on 
families (Ramachandran et al., 2017). Addressing these 
issues can prevent related biopsychosocial sequelae 
and enhance re-epithelization in children with burns 
(Wiechman, 2020). Treatment for these issues typically 
involves non-pharmacological and pharmacological 
interventions (Geagea et al., 2022). 
Therefore, this study aimed to review the methods and 
treatments for managing procedural pain in pediatric 
burnt patients. 
 
LITERATURE REVIEW
Managing pain in burn patients is a challenging and 
intricate matter. There are various pharmacological and 
non-pharmacological methods or therapies to overcome 
anxiety and alleviate pain (Sine, 2019). 

Pharmacologic Pain Management
Procedural pain in children and adults is typically 
managed using sedation-analgesics, opioids, and non-
steroidal anti-inflammatory drugs (NSAIDs) (Minardi 
et al., 2012; Shiferaw et al., 2022b). Narcotics and opioid 
receptor agonists have been used for treating severe burns 
in individuals of  all age groups (Meyer III et al., 2018). A 
study comparing oral morphine and intranasal fentanyl 
found no noticeable differences, suggesting INF at a 
dose of  1.4 mcg/kg 15 minutes before the procedure and 
OM at 0.1 ml every 5 minutes after the procedure. Oral 
trans-mucosal fentanyl citrate (OTFC) and intranasal 
fentanyl (INF) are as effective and favored for pain relief  
in pediatric burn patients during wound care (McPherson 
& Grunau, 2022). OTFC is a promising analgesic due to 
its rapid onset and simple administration. Non-opioid 
analgesics, such as acetaminophen and NSAIDs, are 
beneficial in treating burn pain due to their advantages and 
side effects (Pietsch et al., 2023). A low-dose intravenous 
ketamine injection and oral paracetamol are cost-effective 
and feasible alternatives for treating pain during burn 
procedures, especially in rural and resource-limited areas 
(Dezfouli & Khosravi, 2020; Yang et al., 2018). 

Procedural Analgesia-Sedation
Procedural analgesia-sedation is a technique used to 
prevent children from experiencing pain or recalling 
unpleasant medical procedures (Fagin & Palmieri, 2017). 
Pediatric procedural sedation involves a complex process 
for the child, parents, and medical workers (Grossmann et 
al., 2019). A compliant, relaxed, pain-free pediatric is ideal 
for safe and successful sedation. Ketamine, which causes 
amnesia, analgesia, and sedation, can be administered 
intramuscularly, intranasally, orally, or rectally. Ketamine 
is considered safe and effective for procedural 

analgosedation in pediatrics (Grossmann et al., 2019). 
Studies have focused on various mixtures of  opioids, 
midazolam, dexmedetomidine, kitamine, and propofol to 
provide adequate pain relief  and deep sedation for burned 
children undergoing wound care treatments (Drummond 
et al., 2020; Meyer III et al., 2018). Ketamine-propofol is a 
commonly used combination for pain relief  and sedation 
during burnt care procedures in the operating room. 
Existing research evaluated that Ketamine-Propofol (KP) 
resulted in fewer respiratory incidents and enhanced 
child comfort (Cettler et al., 2022). Both Ketamine-
dexmedetomidine and propofol-opioids are equally safe 
and effective for providing deep sedation and pain relief  
in pediatric burn patients (Grossmann et al., 2019). 

Anesthetic Management
The acute phase of  a burn injury is the period from injury 
onset to wound healing (Anderson & Fuzaylov, 2014). 
Modern burn care success relies on a multidisciplinary 
team of  anesthesiologists, intensivists, nurses, dieticians, 
rehabilitation therapists, and pulmonary care therapists 
(Woodson et al., 2018). Understanding this interdisciplinary 
framework is crucial for effective anesthesia management. 
Surgical treatment often involves removing and grafting 
non-viable burn areas, which can harbor infections 
and compromise heart function (Woodson et al., 2018). 
Severe burns require proper resuscitation for surgical 
procedures, and understanding their pathophysiological 
alterations is crucial for administering appropriate 
anesthetic treatment (Stapelberg, 2020). Pediatric patients 
with severe burn injuries necessitate anesthetic care 
from the outset of  their resuscitation and persist for 
years during reconstructive operations (Fuzaylov, 2020). 
Anesthesiologists, with comprehensive knowledge of  
burn injury pathophysiology, can provide appropriate 
care and manage complications related to burn injuries 
and their treatment (Woodson et al., 2018).

Treatment of  Anxiety and Pain
Burn patients often experience severe pain and anxiety 
during treatment and recovery. Anxiety is closely linked 
to pain, especially after burns and during wound healing. 
Stress and pain can exacerbate discomfort (Fagin 
& Palmieri, 2017).  Children’s unique physiological, 
psychological, and anatomical characteristics make it 
challenging to treat anxiety and discomfort (Fagin & 
Palmieri, 2017). Burn injuries can also affect the efficacy 
and clearance of  drugs, complicating pain management 
and sedation. The aim is to limit discomfort, but complete 
pain relief  during procedures may not be possible (Fagin 
& Palmieri, 2017). Combining opioid analgesics with 
antianxiety drugs is the most common method, as narcotic 
analgesics do not provide full pain relief  (Helander et al., 
2017). Moreover, tranquillizers are frequently prescribed 
to patients to alleviate anxiety and discomfort caused by 
side effects like nausea, vomiting, bleeding, or respiratory 
issues, but they are time-consuming and costly (Seyyed-
Rasooli et al., 2016).



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Non-Pharmacological Treatment for Burn Pain 
Management
Distraction and Multimodal Distraction
A distraction strategy can be employed by directing 
children’s focus on neutral stimuli instead of  suffering or 
distress. For distraction tactics to be effective, the patient 
must attentively focus on them to redirect their attention 
from the unpleasant input (Van Ryckeghem et al., 2018). 
Examples include virtual reality, music distraction, 
computer/iPad distraction, cartoon distraction, and 
interactive gaming (Meyer et al., 2018). Another form of  
distraction method is known as multimodal distraction 
(MMD), which involves the use of  a specially designed 
handled device that engages children through various 
sensory inputs such as movement, touch screen, vibration, 
vision, and sound, without requiring a headset (Meyer et 
al., 2018). 

Virtual Reality and Cartoon Distraction
Virtual reality (VR) utilizes goggles or helmets to offer 
high-resolution, three-dimensional visuals and sounds to 
patients undergoing a procedure (Claudio & Maddalena, 
2014). This non-invasive cognitive distraction technique 
effectively diverts patients’ attention and diminishes their 
pain perception, reducing pain intensity (Pancekauskaitė 
& Jankauskaitė, 2018). Moreover, to reduce pain intensity, 
pediatric patients can be facilitated through entertainment 
strategies such as animated cartoons via smartphones or 
televisions (Zhicai Feng et al., 2018; Z. Feng et al., 2018).

Hypnosis
Hypnosis is a non-pharmacologic method used to manage 
pain and anxiety in children with burn injuries (Chester et 
al., 2016). It involves deep breathing, muscle relaxation, 
and direct hypnotic suggestions (Provençal et al., 2018). 
A randomized controlled trial by Chester et al. 2018 
and a study by Milling et al. 2021 confirmed the efficacy 
of  medical hypnosis in alleviating pain and distress in 
pediatric burn cases (Chester et al., 2018; Milling et al., 
2021). However, non-pharmacological approaches can 
help manage burn pain when used alongside regular 
pharmaceutical care (Eijlers et al., 2019). Existing literature 
demonstrated that virtual reality and distraction effectively 
reduced pain perception and distress during procedures 
(Fardin et al., 2020; Farzan et al., 2023; Scheffler, Koranyi, 
Meissner, Strauss, et al., 2018). 

Anxiety and Stress Reduction Techniques
Non-pharmacologic therapy should be used to reduce 
anxiety in children in intensive care units (ICU) (Ismail et 
al., 2019). This includes environmental adjustments such 
as minimizing noise, ensuring proper lighting for a healthy 
sleep-wake cycle, allowing time for rest and sleep to 
maintain a natural rhythm, scheduling procedures during 
the day, ensuring comfortable positions with cushions, 
and monitoring fluid intake and feeding can enhance 

comfort (Kudchadkar et al., 2022). In addition, a family 
member’s presence can also help alleviate anxiety and 
stress associated with burning pain (Ali, 2015). However, 
establishing a regular schedule can reduce fear and 
increase the child’s sense of  security. Comfort can also be 
given by providing facilities such as earplugs, eye masks, 
noise reduction, and darkness (Baarslag et al., 2017). Play 
specialists can also offer personalized diversion therapy 
to manage pain, fear, and distress in pediatric and burn 
intensive care units. These strategies can help children 
maintain their routines, self-perception, and sense of  
normality (Fagin & Palmieri, 2017). 

Massage and Aromatherapy
Non-pharmacological therapies are used to reduce the 
reliance on analgesics and mitigate their adverse effects. 
This indicates that the cycle of  pain and anxiety decreases 
through massage. Massage is the application of  pressure 
and movement to soft tissues to achieve therapeutic results 
like comfort, healing, and restoration (Najafi Ghezeljeh et 
al., 2017). Traditional massage enhances oxygen uptake. 
However, massage can stimulate cell division, which helps 
the body flush out waste and become more detoxified, 
which promotes relaxation and mental clarity (Miri et al., 
2023; Seyyed-Rasooli et al., 2016). Further, to increase 
blood flow to the soft tissues during massage, the 
following five techniques are used (Gasibat & Suwehli, 
2017; Mobilizations, 2015);

• Effleurage
• Petrissage
• Friction
• Tapotement
• Vibration

Aromatherapy is an alternative therapy that uses plant 
extracts from various parts of  plants, such as flowers, 
leaves, stems, fruits, seeds, and roots. It is commonly used 
in inhalation and massage therapy, with lavender oil extract 
being a popular choice due to its sedative properties (Rafii 
et al., 2020). Chamomile oil, with its strong analgesic and 
anti-inflammatory properties, can be used during massages 
to enhance immunity (Rafii et al., 2020). Aromatherapy 
massage is a popular supplementary therapy in nursing 
due to its user-friendly nature, affordability, and non-
invasive characteristics (Seyyed-Rasooli et al., 2016). 
The practice involves various manipulations, such as 
rubbing, squeezing, stroking, deep massage, and vibrating 
motions. Massage can alleviate fear, promote closeness 
and safety, and improve communication between nurses 
and patients. Aromatherapy massage involves gradually 
absorbing aromatic herbal oils and volatiles through the 
skin, lasting 10 to 30 minutes (Ayik & Özden, 2018). The 
oils and volatile compounds deliver medicinal advantages 
such as sleepiness, pain relief, muscle relaxation, and fever 
reduction. Studies showed that using aromatherapy oils in 
combination with massage has a greater soothing effect 
than massage without oils (Rafii et al., 2020). 



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Music Therapy
Music stimulates calm in patients by impacting the 
central nervous system and redirecting focus away from 
pain (Mofredj et al., 2016). Music has a direct impact on 
the desired alterations in an individual’s emotions and 
behavior, especially in therapeutic environments or high-
pressure situations (van der Heijden et al., 2018). Music 
intervention involves the regular utilization of  music to 
support, sustain, and enhance both physical and well-
being. The major focus of  this intervention is believed to 
be the selection of  a popular piece of  music (Altenmüller 
& Ioannou, 2016; Najafi Ghezeljeh et al., 2017). 

Computer-Tablet Distraction
A computer tablet, also referred to as a tablet, is a prevalent 
technological distraction device (Scheffler, Koranyi, 
Meissner, Strauß, et al., 2018). Pediatric patients can use 
a touchscreen to access movies, cartoons, music, games, 
books, puzzles, comics, audio-video stories, and more. 
Medical professionals use tablets to manage procedures and 
stress-related needs, such as surgery preparation (Scheffler, 
Koranyi, Meissner, Strauß, et al., 2018). Engaging children 
in age-appropriate activities reduces their susceptibility 
to distractions. However, tablets are increasingly used in 
pediatric clinics due to their versatility and user-friendly 
nature (Scheffler, Koranyi, Meissner, Strauß, et al., 2018).

MATERIALS AND METHODS
Search Strategy
To execute this review, recent research and review 
articles/publications based on pain management in 
pediatric burnt patients were considered. The focus 
of  the investigation revolved around the effectiveness 
of  managing pain in treating the burning sensations in 
patients. Data was gathered from electronic databases: 
Google Scholar, PubMed, Publon, Web of  Science, 
NCBI, Hindawi, National Library of  Medicine, 
ResearchGate, MEDLINE, EMBASE database, Science 
Direct, Scopus, Cochrane Central Register of  Controlled 
Trials (CENTRAL), and BioMed. 
For this study, we searched the literature for articles 
addressing the causes, prevalence, and treatments. Studies 
were selected from different years ranging between 2015 
to 2024 using keywords’ ‘pain,’ ‘pediatric pain,’ ‘procedural 
pain,’ ‘pain management,’ ‘burning pain management,’ 
‘treatments for burnt areas,’ ‘procedural wound care,’ 
‘wound dressing,’ ‘analgesics, ’sedatives,’ ‘distraction 
techniques,’ ‘non-pharmacological interventions,’ ‘pain 
intensity,’ ‘adverse effects,’ ‘burn injury,’ ‘pain assessment,’ 
and ‘intervention strategies.’ Search keywords were 
combined using proximity operators (NEAR, NEXT, 
WITHIN) and boolean (AND, OR) operators. Table 1 
indicates the data selection strategy for the review.

Table 1: Data Selection Strategy
Years Search Engines Keywords
2015- 2024 Google Scholar Pain

PubMed Pain Management
NCBI Burning Pain Management
Hindawi Treatments for Burnt Areas
BioMed Managing Strategies
Web of  Science Burning Pain Management
MEDLINE Analgesics
EMBASE Distraction Techniques
ScienceDirect Non-Pharmacological Interventions 
Scopus Burn Injury 
Cochrane Central Register of  Controlled Trials (CENTRAL) Intervention Strategies

A systematic search of  databases was conducted to 
identify pertinent publications. Subsequently, the text 
words present in the title, abstract, and index keywords 
of  the articles were examined and analyzed. Afterwards, a 
comprehensive search was conducted across all databases 
utilizing the identified keywords, index terms, and MeSH 
terms for MEDLINE. Furthermore, a thorough search 
on PubMed, Google Scholar, and Google databases was 
conducted to identify new studies on pain management. 
The search terms were found in titles and abstracts, and 
the entire texts of  the articles were available. This strategy 

serves as a concise overview. Consequently, the contents 
of  the material provided do not thoroughly address the 
management and prevention of  burning pain. However, 
the priority was given to incorporating the most significant 
and relevant studies. 

Quality Assessment Frameworks
The SPIDER framework was employed to determine 
which studies to include in this review, as shown in Table 
2. The PICO model was also used to evaluate databases, 
as shown in Table 3.



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Inclusion Criteria
The titles were filtered based on the following criteria 
for addition and exclusion, rather than their relevance 
to the study. We exclusively selected studies that have 
already been published and peer-reviewed. These studies 
were reviewed in order to better understand the research 
criteria. 

• All research written in English that has been published 
in peer-reviewed journals was included for evaluation..

• Studies describing the importance of  nursing 
strategies were included.

• Studies related to care were included. 
• Studies on interventions for burn care were also included. 
• Reviews of  recent developments in burning pain 

treatment were focused on. 
• Studies related to precautions during treatment and 

management were also considered.
• The research focused on assessing diagnostic 

standards as another area of  interest.
• Studies exploring various non-pharmacological 

methods for pain management, including virtual reality, 
analgesics, sedatives, and diversionary strategies, were 
considered.

• A case report, a case report with review literature, 
a review of  the literature, a retrospective cohort study, 
review articles, and a case-control study were all included 
in the study. 

Exclusion Criteria
The exclusion criteria involve; 

• Only papers written in English were taken into 
consideration.

• Studies that solely focused the science of  burning 
were not included.

• Studies not aimed on improving monitoring and 
therapy were not included in the review.

• The objective was unrelated to procedural pain 
management.

• Studies focused on procedural pain management in 
pediatric patients without burn injuries were not considered. 

• Studies investigating interventions not directly related 
to procedural pain management in burn care. 

• Studies without relevant comparisons or not 
comparing different types of  interventions for procedural 
pain management. 

• Studies lacking predefined findings’ supporting data.
• Studies included adult participants were excluded.

The review did not include studies whose titles were 
relevant to the investigation but whose material was 
unrelated.                                                                

Data Extraction
The two authors reviewed and chose to include all 
reviews independently using the PICO methodology, 
as indicated in Table 3. The researchers extracted and 
sorted the sample size, study type, duplicates, full-text 
articles, and empirical studies using Microsoft Excel and 
a standardized data extraction form, making the review 
approach practicable. The author, the year of  publication, 
and the total number of  studies are examples of  variables. 
The ROBIS technique was utilized by the two reviewers to 
evaluate the methodological qualities. The demographic, 
research selection procedure, inadequate data, time period, 
and location were among the assessed sources of  bias. 

Table 2: SPIDER Framework
Sample Pediatrics, Newborns, Infants, Global. 
Phenomenon of  Interest Procedural pain management in pediatric burnt patients and impact of  burning on 

pediatrics quality of  life. 
Inquiry Strategies and interventions for managing pain.
Design Review of  already published articles using Search engines.
Evaluation Treatments effect on procedural pain management.
Research Type Case reports, controlled studies, cohort studies, prospective randomized studies and 

analyses, systematic reviews, meta-analyses, scoping reviews, and qualitative analysis.

Table 3: PICO Model 
PICO Search strategy
Population Pediatrics, Infants, Newborns
Intervention To improve pain management among burnt pediatrics and to introduce various managing strategies 

to overcome the conditions. pharmacological interventions (e.g., analgesics, sedatives), non-
pharmacological interventions (e.g., distraction techniques, virtual reality), or a combination.

Comparison Comparing different types of  interventions or strategies for procedural pain management. 
Outcome To overcome the effect of  burning and pain in pediatrics and bring improvement with advanced 

procedures and safety measures in treating the conditions associated with this. It may also include 
pain intensity scores, physiological responses to pain (heart rate, blood pressure), duration of  the 
procedure, adverse effects of  interventions, and overall satisfaction with pain management.



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Risk of  Bias – Assessment Tool 
ROBIS (Risk of  Bias in Systematic Reviews) criteria 
were also used to reduce the risk of  bias to some extent 
because they examine both the risk of  bias in a review and 
(when applicable) the review’s relevance to the research 
problem. The four steps in the design of  ROBIS were 
defining the scope, analyzing the evidence, having a face-
to-face meeting, and piloting the tool. Levels of  concern 

ranging from low to high or uncertain were seen for each 
phase 2 area, as well as the percentage of  reviews with 
high or low bias risk (Whiting et al., 2016).
As shown in Figure 1, the use of  signaling questions in 
conjunction with a domain-based approach aligns with 
the most recent methods for estimating the risk of  bias 
tools. The opinion of  an extra reviewer was sought in 
order to settle disputes.

Figure 1: ROBIS Results

Fig. 1 illustrates the graphical representation of  the 
ROBIS findings from a single review. The risk of  bias 
phase assessment is displayed in the final part, which is 
shaded darker. The colored segments represent the issues 
for each phase 2 ROBIS domain.
Additionally, the study purpose, study design, study 
outcomes, justification by results, study limits, ethical 
approval, participant informed consent, funding, and 
study relevance were all taken into consideration by 
the two reviewers who conducted the risk assessment. 
To reduce the possibility of  bias, the third reviewer’s 
viewpoint was also considered. The study’s purpose, 
relevance to the study, its findings, conclusions, ethical 
approval, and informed consent were at low risk, unclear 
for its limitations, design and outcomes, and high risks 
for funding. 

DISCUSSION
Burn injury is a common cause of  illness and death in 
children, majorly with scald damage (42%), followed by 
flame (29%), and contact (10%) (Preston & Ambardekar, 
2020). Non-accidental burns and inhalation injuries 
increase short-term mortality risk (Saeman et al., 2016). 
Burn injuries in children are associated with higher long-
term mortality, especially when the size of  the burn is 
larger (Kazis et al., 2018). However, pediatrics who receive 
care from burn treatment centers with experience had 

lower fatality rates, although there is significant variability 
in management approaches (Preston & Ambardekar, 
2020).
Burns are severe traumas caused by prolonged contact 
with thermal, chemical, electrical, or radioactive materials, 
causing tissue damage. Over 25% of  hospital admissions 
are for children, primarily aged 0-15 (Żwierełło et al., 
2023). Burn injuries involve a complex pathophysiological 
process that results in both localized and systematic 
damage (Kaddoura et al., 2017). Patients with burn 
injuries affecting 30% or more of  their total body surface 
area (TBSA) often suffer systemic repercussions due to 
the release of  catecholamine’s and cytokines (Kaddoura 
et al., 2017). The initial phase, known as burn shock, is 
triggered by fluid moving into the third space, resulting 
in hypovolemia (Cartotto et al., 2022). Burn injuries have 
serious short-term and long-term effects that result 
in high levels of  illness and death, demanding careful 
monitoring and assessment at all stages of  a pediatrics 
treatment (Preston & Ambardekar, 2020).   

Classification of  Burns
The severity of  burn injuries is determined by assessing 
the TBSA affected and the depth of  the burn (Brekke 
et al., 2023). Adult TBSA is often determined using the 
rule of  nines, while children use the Berkow method to 
calculate burn size based on the area of  burn on a specific 



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body part (Tocco-Tussardi et al., 2018). Major burn 
injuries in children include full-thickness burns exceeding 
10% of  the TBSA, and partial thickness burns exceeding 
20% in infants (Giretzlehner et al., 2021), burns affecting 
critical areas, inhalation, chemical or electrical burns, or 
burns in individuals with significant pre-existing medical 
conditions (Rice & Orgill, 2021). There are four categories 
of  burns determined by the extent of  the damage:

• First-degree burns cause redness and inflammation in 
the outer layer of  the skin, often causing discomfort and 
healing without surgery.

• Second-degree burns extend from the epidermis into 
the dermis, causing discomfort characterized by redness, 
swelling, blistering, and requiring surgical excision and 
grafting.

• Third-degree burns have a leathery texture, affecting 
the dermis and epidermis, potentially leading to white, 
brown, or black discoloration. 

• Fourth-degree burns penetrate deeply into muscles, 
bones, and tissues, causing significant agony and 
necessitating excision and grafting for healing (Dries & 
Marini, 2017).

Mechanism of  Burn Pain
Acute burn injuries cause pain in peripheral nociceptors, 
sensory neurons transmitting signals to the brain and 
thalamus (Santiago et al., 2020). Repetitive stimulation 
can cause hyperalgesia, reducing neuron thresholds and 
increasing sensitivity to future stimuli (Santiago et al., 
2020). C fibers and dorsal horn neurons are not fully 
formed before postnatal life, and infants have lower pain 
thresholds. Major burn injuries trigger a local and systemic 
inflammatory response syndrome, releasing mediators 
like complement, histamine, serotonin, cytokines, and 
prostanoids (Lee & Neumeister, 2020).

Pain Assessment in Pediatrics
Three primary approaches of  pain assessment in pediatric 
patients are; self-report, behavioral or observational, 
and physiological measures (Laures et al., 2019). 
Comprehensive evaluation is essential for successful 
pain management in these individuals. However, self-
reporting is a crucial element in the pediatric population 
(Cohen et al., 2020; Jaaniste et al., 2019). Three major 
self-reporting methods for pain assessment include the 
Faces Pain Scale-Revised (FPS-R), Visual Analog Scale 
(VAS), and Numeric Rating Scale (NRS). Behavioral 
and observational evaluations play an important role 
(Lundeberg & Lundeberg, 2013; Shimoji & Aida, 2021), 
which is typically facilitated by measurements such as 
FLACC (Face, Legs, Activity, Cry, Consolability) (Babl 
et al., 2012). Additionally, physiological indicators such 
as heart rate and other vital signs are utilized for pain 
assessment (Gosnell & Thikkurissy, 2019). Despite the 
various methodologies used for evaluation, self-report 
is considered as a gold standard, particularly for older 
children (2-5 years) (Pancekauskaitė & Jankauskaitė, 2018).

Multifaceted Dimension of  Pain Experience
There are multiple components to the experience of  
pain that can be evaluated independently and may be 
influenced differently (Scheffler, Koranyi, Meissner, 
Strauß, et al., 2018);

• A sensory component (intensity of  pain)
• An affective component (unpleasantness of  pain)
• A cognitive component (time spent focusing on the 

pain)

Treatment and Management Guidelines
Burn injuries are considered one of  the most tragic 
events a person can endure while quantifying pain 
remains challenging (Foster, 2014). Treatment for burn 
injuries includes debridement, daily wound care, surgery, 
and extended physical therapy to alleviate the intense and 
persistent pain experienced by patients (Drummond et al., 
2020). Managing burn pain is inherently challenging due 
to the intricate structure and dynamic alterations caused 
by repeated treatments and manipulations of  painful 
lesion sites (Ahuja et al., 2016). Burn centers need to 
adopt a systematic approach to manage burn pain, despite 
evidence of  inadequate treatment and varied practice 
standards over the past twenty years (Rowan et al., 2015). 
It is crucial to differentiate between pain and anxiety, 
ensuring patients are comfortable, alert, and focused. 
Burn pain should be promptly addressed, involving an 
IV line, resuscitation, and administering opioids. Opioids 
may be combined with adjuncts like benzodiazepines 
to manage pain (Carey et al., 2021). However, regularly 
assessing patient’s pain and anxiety levels using established 
metrics is recommended (Yastı et al., 2015). It is crucial to 
educate staff, patients, and families on burn-related pain 
and its harmful consequences. The educational program 
should address addiction and pain communication 
through pain scales (Nosanov et al., 2020). A personalized 
treatment plan considers individual opioid effectiveness 
and drug tolerance development (Foster, 2014). The 
Joint Commission on Accreditation of  Healthcare 
Organizations and physical speciality groups outline 
patient monitoring levels, especially for those needing 
increased sedation and analgesia. The burn care team 
must prioritize addressing burn-related pain in all patient 
care aspects (Carrougher et al., 2020; Pruskowski et al., 
2020). 
The management of  burn pain in children can be 
enhanced by developing personalized treatment protocols 
that consider individual characteristics, burn severity, and 
cultural factors. Long-term outcome studies are needed 
to assess the long-term effects of  pain management 
methods on pediatrics. Age-specific studies should be 
conducted to understand pain changes in newborns and 
young children. Interdisciplinary training for healthcare 
providers working with pediatric burn patients is 
recommended, and increased public awareness about 
burn injuries and management strategies can improve 
treatment compliance. 



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CONCLUSION
In conclusion, this review found that pediatrics often 
suffer burn injuries, which can be treated in outpatient 
clinics through pharmacologic and non-pharmacologic 
interventions or require collaboration between 
pediatricians and regional burn programs for acute and 
long-term care. The review demonstrated that patients 
experience unmanageable physical and psychological pain, 
urging medical professionals to examine burn patients 
and establish a multidisciplinary pain management team. 
To apply safe and effective pain management strategies, 
this team may include surgeons, critical care specialists, 
anesthesiologists, nurses, psychologists, and social 
workers. It also highlights perspectives and suggestions 
for future research to address this significant clinical issue. 
 
LIMITATIONS AND STRENGTHS

• The review highlights the importance of  personalized, 
multimodal pain treatment methods for vulnerable 
patients’ health and efficiency. However, potential 
limitations include limited generalizability, publication 
bias in outcome measures, resource intensiveness, lack of  
long-term data, and variability in patient response. 

• Excluding non-peer-reviewed sources may result in 
the omission of  valuable insights.

• In contrast, the review has several strengths as a 
comprehensive search strategy, complex methodology, 
and quality assessment tools like ROBIS, PICO model, 
and SPIDER framework were used. 

• It covers various treatments like non-pharmacological 
methods, procedural analgesia-sedation, pharmacological 
interventions, and anesthetic care. 

• The review emphasizes clinical consequences, 
interdisciplinary anesthetic delivery, and pain management 
methods for pediatric burn care professionals.

Contribution of  Knowledge
This review explored the treatment of  burn pain 
in pediatrics using both pharmaceutical and non-
pharmaceutical methods. Quality evaluation tools like 
PICO model, SPIDER framework, and ROBIS were 
employed. It provided a comprehensive understanding of  
burn pain’s sensory, emotional, and cognitive components. 
The review on procedural pain management in pediatric 
burn patients contributes by providing insights into 
effective interventions and tailored approaches for 
managing pain in this specific population. It helps 
inform clinical practice, identifies research gaps, and 
promotes patient-centered care. Overall, the review 
enhances understanding of  procedural pain management 
in pediatric burn patients and guides efforts to improve 
their pain relief  outcomes and overall quality of  care.

Novelty
This review demonstrated pediatric burn pain treatment 
through several interventions and provided management 
guidelines and insights on pain assessment tools, 
emphasizing the need for personalized strategies to 

improve care. The novelty in this topic lies in its focus on 
procedural pain management specifically in pediatric burnt 
patients. While pain management in pediatric populations 
and burn care are well-studied areas, the intersection of  
these two domains may present unique challenges and 
considerations. Understanding effective methods and 
treatments tailored to this specific demographic could 
contribute to improving the quality of  care and outcomes 
for pediatric burn patients. Additionally, exploring 
novel interventions or approaches specifically targeted 
at managing procedural pain in this population could 
represent a novel contribution to the field of  pediatric 
pain management.

Research Gap
Research on burn pain management in children is 
limited, mainly focusing on evaluating therapies but not 
integrating them into personalized treatment plans. The 
research gap in procedural pain management for pediatric 
burn patients includes a lack of  high-quality evidence, 
standardized protocols, and studies on understudied 
interventions. Additionally, age-specific considerations, 
long-term outcomes, patient-centered outcomes, and 
cost-effectiveness analyses are lacking.  Closing these 
gaps could improve pain management and overall care 
for pediatric burn patients undergoing procedures.
This review covered various aspects of  the treatment 
and management of  procedural pain in burnt pediatric 
patients. Future research can assess lasting effects and 
understanding of  cultural and environmental factors. 
However, addressing these gaps will improve the 
specialization and effectiveness of  pain management 
strategies, leading to better patient outcomes. 

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